Search

Supplemental Digital Content is available in the text.

Introduction:Low testosterone (LowT) has been suggested to be associated with increased ASCVD risk and mortality, but results are conflicting across studies. We evaluated the independent relationship between low testosterone levels in adult males and ASCVD using data from an EHR-based database. Methods Cross-sectional study using the Houston Methodist CVD Learning Health System Registry, which includes data from 1.1 million patients aged ≥18 years (June 2016-April 2022). Analyses were restricted to men, and those on testosterone replacement therapy were excluded. We evaluated the associations between total testosterone levels (categorized as quartiles [Q], lowest Q as exposure of interest and highest Q as reference) and ASCVD (CAD, PAD, stroke), using logistic regression. Conditions and risk factors were identified using ICD 10-CM codes.Results:We evaluated 30,150 men ≥18 years (mean age 55.3 years, 12% NHB, 15% Hispanics) with testosterone level data. Men in testosterone Q1 (lowest levels: ≤285 ng/dl) had higher prevalence of almost all risk factors and composite ASCVD compared to Q4 (highest levels: ≥515 ng/dl) (Panel A).In unadjusted analyses, men in testosterone Q1 vs Q4 had higher odds of ASCVD (OR 1.54, 95% CI 1.41-1.68). In multivariable adjusted logistic regression, the increased odds persisted adjusting for age, sex, and race OR 1.33 (CI 1.21 - 1.46), while it was fully attenuated (OR 1.04 CI 0.94 - 1.14) after adjusting for risk factors (DM, HTN, dyslipidemia, obesity) (Panel B).The attenuation in association with prevalent ASCVD was highest adjusting for DM (67%) and HTN (58%) (Panel C).Similar results were noted when cutoff of <200 ng/dl was used for LowT.Conclusions:ASCVD and CV risk factors are widely prevalent among men with LowT. The association between LowT and ASCVD might be related to CV risk factors, mainly hypertension and DM. Early identification and intensive CV risk factor management among men with LowT levels may help reduce their risk of ASCVD.

Background:Optimizing modifiable cardiovascular risk factors is critical to achieving AHA’s 2020 Strategic Impact Goals. Neighborhood and urban factors with a supportive walkable environment can enhance physical activity and hence impact CVH across a wide range of populations. We assessed whether a more walkable environment is associated with CV risk factor burden irrespective of CVD burden among a large diverse population within an integrated health system.Methods:Cross-sectional study using data from 1.01 million patients aged 18+ years in the Houston Methodist Cardiovascular Disease Learning Health System Registry (2016-2021). Individuals lacking NW (177,674) & BMI <18.5 kg/m2(27,065) were excluded. Neighborhood walkability (NW) was defined using 2019 Walk Score. Patients were assigned to 1 of 4 NW categories (Figure). Study participants were classified as poor (>3 CV risk factors), average (1-2 CV risk factors) or optimal (0 CV risk factors).Results:We included 901,860 patients (mean age 51.88, female 59%, NHB 15%, and 16% Hispanics), most of these (86%) resided in the 2 least walkable neighborhoods. Age-adjusted prevalence of CV risk factors was significantly lower among participants in most favorable walkable neighborhoods irrespective of CVD status (Figure). In adjusted analysis, favorable NW (somewhat/very walkable) vs unfavorable NW (car dependent) was associated with 2-fold odds for optimal vs poor CVD risk (OR 2.07 95%CI: 2.01-2.12) among those without CVD. Similar results were found in those with CVD (OR 1.58 95% CI:1.41-1.77).Conclusions:Our findings demonstrate favorable association between neighborhood walkability and the CVD risk factors burden in large population of about 1 million individuals. These robust findings support multilevel health system stakeholder engagements and investments in walkable neighborhoods as a viable tool for mitigating growing burden of modifiable CV risk factors.

Introduction:Less than 50% adherence is reported 1 year after initiating antihypertensives. We examined social disparities in cost-related medication non-adherence (CRN) by insurance and family income categories in adults with hypertension.Methods:We used National Health Interview Survey 2014-2017 data from adults who reported hypertension and were taking antihypertensive medications. Respondents reported their insurance plan and family income. A cumulative SDoH index was created by aggregating 45 determinants from 6 domains, and respondents were grouped by quartiles (SDoH-Q1 to Q4). Higher SDoH quartiles indicated greater disadvantage. CRN was present if an individual skipped medication to save money, took less medicine to save money, or delayed filling a prescription to save money in the last 12 months.Results:A total of 35,893 adults managed for hypertension were surveyed, with a mean age 62.48 [SD 14.24] years, female 51.3%). The prevalence of CRN was 9.5%. The uninsured (34.6%) and those with low income were most likely to report CRN. Regardless of insurance or income, higher SDoH quartile groups were more likely to report CRN. This trend was accentuated among the uninsured and the middle-income group. Adjusting for demographics and comorbidities, the least increment in the odds of CRN with SDoH quartiles was seen among Medicare beneficiaries and low-income: SDoH-Q4 was associated with OR = 8.47 (95%CI, 2.11, 33.93) for Medicare beneficiaries, and OR = 17.80 (95%CI, 7.91, 40.03) for low-income. The highest increment in the odds of CRN with SDoH quartiles were observed with the uninsured (OR = 22.89; 95%CI [4.91, 106.81]), and the middle-income group (OR = 21.57; 95%CI [13.78, 33.77]).Conclusion:While cumulative social disadvantage was associated with higher cost-related medication non-adherence among adults on medications for hypertension, this association was stronger in the uninsured, Medicaid beneficiaries, and the middle-income group.

Introduction:Non-alcoholic fatty liver disease and liver fibrosis (LF) are associated with atherosclerotic cardiovascular disease (ASCVD). In this study, we aim to assess if the Fibrosis-4 index (FIB-4), a surrogate marker for liver fibrosis that is easily calculated from information within electronic medical records, is associated with composite and subgroups of ASCVD across a wide range of demographics and risk profile in a large integrated healthcare system.Methods:This cross-sectional study analyzed data on 606,056 individuals (>18 years old) from the Houston Methodist Cardiovascular Disease Learning Health System Registry (June 2016-April 2022). We implemented the FIB-4 score for patients based on simultaneous presence of 4 variables (age, AST, ALT, and platelet count). LF risk was categorized according to previously described cutoffs: Low (<1.3), Intermediate (1.3-2.67), and High (>2.67). ASCVD (CAD, PAD, and Stroke) were identified using ICD-10-CM codes.Results:In the final study population (mean age: 54 years, 60% females, 16% Non-Hispanic Black, and 16% Hispanic adults), 27% of individuals were at moderate-risk and 8% at high-risk for LF based on the FIB-4 index. Moderate-high risk LF is associated with higher age-adjusted prevalence of both composite and subcategories of ASCVD (CAD, PAD, Stroke). Accounting for demographics, CV risk factors, and ASA/statin use, moderate and high-risk LF was associated with a 1.32 (95% CI 1.30-1.35) and 1.67 (95% CI 1.62-1.72) odds of prevalent composite ASCVD, respectively, compared to low-risk LF. Similar associations were noted for increasing LF risk and prevalence of ASCVD subcategories.Conclusions:In a large integrated health system, a moderate-high risk of liver fibrosis (based on FIB-4 index) is significantly associated with a spectrum of ASCVD conditions. FIB-4 index based early identification and management of these high-risk individuals need to be evaluated in further implementation studies.

•Food insecurity and CVD share a circular association.•Association may be stronger for racial/ethnic minorities and single mothers.•Greater investment and organization are needed to address this association.•Targeting food insecurity may reduce the nationwide burden of CVD.

Middle Eastern (ME) immigrants are one of the fastest-growing groups in the US. Although ME countries have a high burden of atherosclerotic cardiovascular disease (ASCVD), the cardiovascular health status among ME immigrants in the US has not been studied in detail. This study aims to characterize the cardiovascular health status (CVD risk factors and ASCVD burden) among ME immigrants in the US.

Introduction:Individuals with CVD are at higher risk of COVID-19 complications. However, the impact of social disadvantage on COVID-19 outcomes has not been fully evaluated in people with CVD. We assessed Area Deprivation Index (ADI) associations with COVID-19 positivity, severity, and in-hospital mortality among patients with and without CVD.Methods:We used the Houston Methodist COVID-19 Surveillance and Outcomes Registry (CURATOR) of 152,850 consecutive adults tested for COVID-19 between March 6 and October 31, 2020. CVD status was obtained from electronic health records. We matched ZIP codes of patients’ residences to state-level ADI using the Neighborhood Atlas and Census Block information from the American Community Survey 2018. ADI was categorized into quintiles of increasingly higher social disadvantage. For reference, we also analyzed the data of patients without CVD.Results:The median ADI ranking of the total sample (mean age 51.3 years; 60% women) was 4 (IQR 1-6). Overall, 37,468 (24.5%) patients had CVD and their median ADI was higher than those without CVD. Of the total sample, 11.9% tested positive for COVID-19 (no CVD: 12.7%; CVD: 9.4%). COVID-19 patients with CVD (v. no CVD) were more likely to be hospitalized (68.4% v. 27.1%), receive intensive care (34.9% v. 16.4%), and die (16.2% v. 4.0%) during admission. Adjusting for demographics and comorbidities, the odds of COVID-19 positivity and hospitalization were at least 50% higher in the most (compared to the least) deprived groups, irrespective of CVD status (Figure). In contrast, associations were null between ADI, need for intensive care, and in-hospital mortality.Conclusions:Individuals from the most deprived neighborhoods were more likely to test positive and be hospitalized for COVID-19, irrespective of CVD status. However, once hospitalized, individuals from disadvantaged areas were not at increased risk of requiring intensive care or dying during admission.

Background:Health-related expenditures due to diabetes mellitus (DM) are rising in the US. Medication nonadherence is associated with worse health outcomes, particularly among individuals with DM who require uninterrupted treatment. We sought to determine whether patients with DM in the US report cost-related nonadherence (CRN), a potential consequence of rising drug costs.Methods:We used the National Health Interview Survey (2013-18), a nationally representative study, to identify participants with and without self-reported DM. Participants were considered to have experienced CRN if during the preceding year they reported skipping doses, taking less medication, or delaying filling a prescription to save money.Results:Of the 20,326 participants with DM, a weighted 14% (or 3 million annually) experienced CRN, including 9.5% skipping doses, 9.9% taking less medicine, and 11.8% delaying prescription filling to save money. Compared to those without DM (N=145,186), participants with DM reported a higher prevalence of CRN, with the largest differences being observed among non-elderly adults (Figure). Among non-elderly adults with DM, a weighted 19.4% (or 2.3 million annually) reported CRN. In multivariable logistic regression models, the main drivers of CRN among participants with DM were lack of insurance (OR 4.34, 95% CI 3.49, 5.39), younger age (OR 3.43, 95% CI 2.65, 4.44), low income (OR 1.82, 95% CI 1.58, 2.09), use of insulin (OR 1.19, 95% CI 1.04, 1.35), and unfavorable risk factor profile (OR 1.53, 95% CI 1.21, 1.93) (Table).Conclusion:In the US, 1 in 7 adults with DM reported CRN, and the burden was highest among non-elderly adults. Cost represents a serious barrier for therapy adherence among individuals with DM in the US, particularly among the most vulnerable. Removing financial barriers to accessing medications may improve adherence to essential therapies among individuals with DM, and ultimately improving outcomes.

Introduction:The association between body mass index (BMI) and mortality risk has been previously shown to follow a J- shaped pattern, with a greater mortality risk at the lowest and highest BMI levels. However, this association has not been fully evaluated in a population with atherosclerotic cardiovascular disease (ASCVD). We examined the BMI-mortality associations in the general population, and in a population with ASCVD.Methods:We used data from 2006-2014 National Death Index-linked National Health Interview Survey, a US nationally representative survey, for adults ≥ 18 years. Participants were classified based on self-reported ASCVD. BMI was calculated based on self-reported height and weight and was classified as normal/overweight (BMI 18.5-29.9 kg/m2), obesity class 1 (30-34.9 kg/m2), class 2 (35-39.9 kg/m2), and class 3 (≥40 kg/m2); participants who were underweight (<18.5 kg/m2) were excluded. Multivariable cox proportional hazards models were used to examine the risk of all-cause, cardiovascular, and non-cardiovascular mortality.Results:A total of 252,9568 adults, including a weighted 8.1% (or 18.6 million annually) with ASCVD, were included in the analysis. During a median follow-up of 4.5 (IQR: 2.5-6.8) years, (1179 million person-years), mortality rates, both cardiovascular and non-cardiovascular, were higher in the ASCVD group compared to the general population (Fig: panel A). In the general population, those with obesity class 3 had a higher risk of cardiovascular and non-cardiovascular mortality compared to individuals with normal/overweight, whereas individuals with obesity class 1 had a lower non-cardiovascular mortality risk. An overall similar pattern of association was observed in the ASCVD population in non-cardiovascular, but not cardiovascular, mortality (Fig: panel B).Conclusion:Greater BMI categories were associated with higher non-cardiovascular, but not cardiovascular, mortality in the ASCVD population.

Introduction:Middle Eastern (ME) immigrants are one of the fastest-growing groups in the US. Several studies have noted a relatively high burden of CVD in ME countries. In the US, while their risk profile has been partially described as part of immigrant studies, the burden of risk factors and ASCVD have not been studied in detail among ME immigrants.Methods:We used 2012-2018 data from the National Health Interview Survey (NHIS), a US nationally representative survey. ME origin was ascertained through self-reported region of birth. ASCVD and CVD risk factors were also self-reported. We compared these to US-born non-Hispanic white (NHW) individuals in the US, using chi-square tests and logistic regression models.Results:Among 139,778 adults included, 886 (representing 1.3 million individuals, mean age 46.8) were of ME origin, and 138,892 were US-born NHWs (representing 150 million US adults, mean age 49.3). ME participants were more likely to have higher education, lower income and be uninsured. The age-adjusted prevalence of hypertension (22.7% vs 27.8%) and obesity (22.1% vs 32%) were significantly lower in MEs vs NHWs participants, respectively. There were no significant differences between the groups in the age-adjusted prevalence of ASCVD, diabetes, hyperlipidemia, and smoking. Only physical inactivity was higher among ME individuals (Fig). In multivariable analyses, ME participants had lower odds of hypertension (OR 0.71, 95% CI 0.61, 0.83) and obesity (OR 0.61, 95% CI 0.52, 0.72), and higher odds of physical inactivity (OR 1.30, 95% CI 1.11, 1.53), with no significant differences in the other factors or ASCVD (Fig).Conclusions:ME immigrants in the US exhibit a more favourable cardiovascular risk profile compared to NHWs. Further studies are needed to determine whether this finding is related to lower risk, selection of a healthier ME subgroup in NHIS, or possible under-detection of cardiovascular risk factors in ME immigrants living in the US.

: The Asian American population in the U.S. comprises various, ethnically diverse subgroups. Traditionally, this population has been studied as a single, aggregated group, potentially masking differences in risk among subgroups. Analyses using disaggregated data can help better characterize the health needs of different Asian subpopulations and inform targeted, effective public health interventions. We assessed the prevalence of cardiovascular disease (CVD) risk factors and atherosclerotic CVD (ASCVD) and their associations with socioeconomic factors among Chinese, Asian Indian, Filipino and Other Asian subjects, compared with non-Hispanic White (NHW) subjects in the U.S.

To examine the association of social determinants of health (SDOH) on prevalence of stroke in non-elderly adults (<65 years of age).

Cardiovascular disease remains a major contributor to morbidity and mortality in the US and elsewhere, and stroke is a leading cause of disability worldwide. Despite recent success in diminishing stroke incidence in the general US population, in parallel there is now a concerning propensity for strokes to happen at younger ages. Specifically, the incidence of stroke for US adults 20–44 years of age increased from 17 per 100,000 US adults in 1993 to 28 per 100,000 in 2015. Occurrence of strokes in young adults is particularly problematic as these patients are often affected by physical disability, depression, cognitive impairment and loss of productivity, all of which have vast personal, social and economic implications. These concerning trends among young adults are likely due to increasing trends in the prevalence of modifiable risk factors amongst this population including hypertension, hyperlipidemia, obesity and diabetes, highlighting the importance of early detection and aggressive prevention strategies in the general population at early ages. In parallel and compounding to the issue, troublesome trends are evident regarding increasing rates of substance abuse among young adults. Higher rates of strokes have been noted particularly among young African Americans, indicating the need for tailored prevention and social efforts targeting this and other vulnerable groups, including the primordial prevention of risk factors in the first place, reducing stroke rates in the presence of prevalent risk factors such as hypertension, and improving outcomes through enhanced healthcare access. In this narrative review we aim to emphasize the importance of stroke in young adults as a growing public health issue and increase awareness among clinicians and the public health sector. For this purpose, we summarize the available data on stroke in young adults and discuss the underlying epidemiology, etiology, risk factors, prognosis and opportunities for timely prevention of stroke specifically at young ages. Furthermore, this review highlights the gaps in knowledge and proposes future directions moving forward.

Atherosclerotic cardiovascular disease (ASCVD) and chronic obstructive pulmonary disease (COPD) are among the leading causes of morbidity, mortality, and economic burden in the United States (US). While previous reports have shown that an optimal cardiovascular risk factor (CRF) profile is associated with improved outcomes among COPD patients, the impact of ASCVD and CRF on healthcare costs and resource utilization is not well described.